Андрология и генитальная хирургия. 2021; 22: 76-84
Реконструкция опорно-связочного аппарата малого таза при робот-ассистированной радикальной простатэктомии как этап кривой обучения
https://doi.org/10.17650/1726-9784-2021-22-1-76-84Аннотация
Цель исследования – оценить результаты робот-ассистированной лапароскопической радикальной простатэктомии в рамках кривой обучения одного хирурга; оценить влияние реконструкции опорно-связочного аппарата малого таза на раннее восстановление удержания мочи.
Материалы и методы. В зависимости от даты операции 246 пациентов разделены на 3 группы. Анализируемые данные собирались проспективно и ретроспективно. Оценивались предоперационные показатели (стадия по TNM, ISUP, простатический специфический антиген), интраоперационные показатели (длительность операции, объем кровопотери, вид и характер операции, тип реконструкции опорно-связочного аппарата малого таза) и послеоперационные показатели (длительность дренирования мочевого пузыря уретральным катетером, степень и сроки восстановления удержания мочи и эректильной функции). Реконструкции опорно-связочного аппарата малого таза осуществлялись путем восстановления фасции Денонвилье (шов Рокко), а также путем сшивания мышечных волокон шейки мочевого пузыря с периуретральными тканями и остатками пубопростатических связок для стабилизации таким образом уретровезикального комплекса.
Результаты. Все операции были успешно завершены без конверсий или переливаний. Медиана длительности операции составила 160 мин (p = 0,0001). Медиана кровопотери составила 173,3 см3 (p = 0,0002). Средний объем предстательной железы – 36 см3 (29–47,5 см3), а общая частота положительного хирургического края составила 12,82 %. Общая частота восстановления удержания мочи: 51,6 % – через 3 мес, 63,7 % – через 6 мес (p >0,05). В группе пациентов с реконструкцией опорно-связочного аппарата малого таза частота восстановления удержания была выше по сравнению с группой без реконструкции: 64,1 % vs 45,3 % (через 3 мес, р = 0,041) и 74,7 % vs 62,3 % (через 6 мес, р = 0,034).
Заключение. Время операции, объем кровопотери значительно снизились с увеличением количества проведенных оперативных пособий. Отмечено значимое улучшение показателей раннего восстановления удержания мочи в группе с выполнением реконструкции опорно-связочного аппарата малого таза.
Список литературы
1. Ferlay J., Soerjomataram I., Dikshit R. et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136(5):E359–86. DOI: 10.1002/ijc.29210.
2. Mottet N., Bellmunt J., Bolla M. et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2017;71(4):618–29. DOI: 10.1016/j.eururo.2016.08.003.
3. Walsh P.C., Partin A.W., Epstein J.I. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol 1994;152(5 Pt 2):1831–6. DOI: 10.1016/s0022-5347(17)32396-0.
4. Bolenz C., Freedland S.J., Hollenbeck B.K. et al. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2014;65(2):316–24. DOI: 10.1016/j.eururo.2012.08.059.
5. Ahlering T.E., Skarecky D., Lee D., Clayman R.V. Successful transfer of open surgical skills to a laparo - scopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003;170(5):1738–41. DOI: 10.1097/01.ju.0000092881.24608.5e.
6. Ko Y.H., Ban J.H., Kang S.H. et al. Does robot-assisted laparoscopic radical prostatectomy enable to obtain adequate oncological and functional outcomes during the learning curve? From the Korean experience. Asian J Androl 2009;11(2):167–75. DOI: 10.1038/aja.2008.52.
7. Volpe A., Ahmed K., Dasgupta P. et al. Pilot Validation Study of the European Association of Urology Robotic Training Curriculum. Eur Urol 2015;68(2):292–9. DOI: 10.1016/j.eururo.2014.10.025.
8. Lovegrove C., Novara G., Mottrie A. et al. Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment. Eur Urol 2016;69(3):526–35. DOI: 10.1016/j.eururo.2015.10.048.
9. Urkmez A., Ranasinghe W., Davis J.W. Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy. Transl Androl Urol 2020;9(6):3036–48. DOI: 10.21037/tau.2020.03.36.
10. Briganti A., Larcher A., Abdollah F. et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012;61(3):480–7. DOI: 10.1016/j.eururo.2011.10.044.
11. Mottet N., van den Bergh R.C.N., Briers E. et al. EAU-ESTRO-ESURSIOG Guidelines on Prostate Cancer 2018, in European Association of Urology Guidelines. 2018 Ed. 2018, European Association of Urology Guidelines Office: Arnhem, The Netherlands. p. 54.
12. Patel V.R., Tully A.S., Holmes R., Lindsay J. Robotic radical prostatectomy in the community setting – the learning curve and beyond: initial 200 cases. J Urol 2005;174(1):269–72. DOI: 10.1097/01. ju.0000162082.12962.40.
13. Vickers A.J., Savage C.J., Hruza M. et al. The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study. Lancet Oncol 2009;10(5):475–80. DOI: 10.1016/S1470-2045(09)70079-8.
14. Doumerc N., Yuen C., Savdie R. et al. Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years. BJU Int 2010;106(3):378–84. DOI: 10.1111/j.1464-410X.2009.09158.x.
15. Trinh Q.D., Sammon J., Sun M. et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 2012;61(4):679–85. DOI: 10.1016/j.eururo.2011.12.027.
16. Rocco B., Matei D.V., Melegari S. et al. Robotic vs open prostatectomy in a laparo- scopically naive centre: a matched-pair analysis. BJU Int 2009;104(7):991–5. DOI: 10.1111/j.1464-410X.2009.08532.x.
17. Yossepowitch O., Briganti A., Eastham J.A. et al. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. Eur Urol 2014;65(2):303–13. DOI: 10.1016/j.eururo.2013.07.039.
18. Hong Y.M., Sutherland D.E., Linder B., Engel J.D. “Learning curve” may not be enough: assessing the oncological experience curve for robotic radical prostatectomy. J Endourol 2010;24(3):473–7. DOI: 10.1089/end.2009.0121.
19. Patel V.R., Palmer K.J., Coughlin G., Samavedi S. Robot-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. J Endourol 2008;22(10):2299–305. DOI: 10.1089/end.2008.9711.
20. Ploussard G., de la Taille A., Moulin M. et al. Comparisons of the perioperative, functional, and oncologic outcomes after robot-assisted versus pure extraperitoneal laparoscopic radical prostatectomy. Eur Urol 2014;65(3): 610–9. DOI: 10.1016/j.eururo.2012.11.049.
Andrology and Genital Surgery. 2021; 22: 76-84
Reconstruction of the ligamentous apparatus of the lower pelvis in robot-assisted radical prostatectomy as a stage of the learning curve
https://doi.org/10.17650/1726-9784-2021-22-1-76-84Abstract
Objective of the study. To evaluate results of robot-assisted laparoscopic radical prostatectomy in the framework of a surgeon’s learning curve; to evaluate the effect of reconstruction of the ligamentous apparatus of the lower pelvis on early recovery of urine retention.
Materials and methods. 246 patients were divided into 3 groups depending on the surgery date. The analyzed data was accumulated prospectively and retrospectively. Preoperative characteristics (TNM stage, PSA, ISUP), intraoperative characteristics (surgical time, blood loss volume, surgery type and character, type of reconstruction of the ligamentous apparatus of the lower pelvis) and postoperative characteristics (duration of bladder drainage with a urethral catheter, level and time of recovery for urine retention and erectile function) were evaluated. Reconstruction of the ligamentous apparatus of the lower pelvis was performed through reconstruction of the Denonvillier fascia (Rocco stitch), as well as through suturing fibers of the bladder neck with periurethral tissues and residual puboprostatic ligaments for stabilization of the urethrovesical complex.
Results. All operations were successfully completed without conversions or transfusions. Median surgical time was 160 minutes (p = 0.0001). Median blood loss was 173.3 cm3 (p = 0.0002). Mean prostatic volume was 36 cm3 (29–47.5 cm3), and overall frequency of positive surgical margin was 12.82 %. Overall frequency of urine retention recovery was 51.6 % after 3 months, 63.7 % after 6 months (p >0.05). In the patient group with reconstruction of the ligamentous apparatus of the lower pelvis, frequency of urine retention recovery was higher than in the group without reconstruction: 64.1 % vs 45.3 % (after 3 months, р = 0.041) and 74.7 % vs 62.3 % (after 6 months, р = 0.034).
Conclusion. Surgical time, blood loss were significantly decreased with the number of performed operative interventions. Significant improvement of early urine retention recovery was observed in the patient group with reconstruction of the ligamentous apparatus of the lower pelvis.
References
1. Ferlay J., Soerjomataram I., Dikshit R. et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 2015;136(5):E359–86. DOI: 10.1002/ijc.29210.
2. Mottet N., Bellmunt J., Bolla M. et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2017;71(4):618–29. DOI: 10.1016/j.eururo.2016.08.003.
3. Walsh P.C., Partin A.W., Epstein J.I. Cancer control and quality of life following anatomical radical retropubic prostatectomy: results at 10 years. J Urol 1994;152(5 Pt 2):1831–6. DOI: 10.1016/s0022-5347(17)32396-0.
4. Bolenz C., Freedland S.J., Hollenbeck B.K. et al. Costs of radical prostatectomy for prostate cancer: a systematic review. Eur Urol 2014;65(2):316–24. DOI: 10.1016/j.eururo.2012.08.059.
5. Ahlering T.E., Skarecky D., Lee D., Clayman R.V. Successful transfer of open surgical skills to a laparo - scopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. J Urol 2003;170(5):1738–41. DOI: 10.1097/01.ju.0000092881.24608.5e.
6. Ko Y.H., Ban J.H., Kang S.H. et al. Does robot-assisted laparoscopic radical prostatectomy enable to obtain adequate oncological and functional outcomes during the learning curve? From the Korean experience. Asian J Androl 2009;11(2):167–75. DOI: 10.1038/aja.2008.52.
7. Volpe A., Ahmed K., Dasgupta P. et al. Pilot Validation Study of the European Association of Urology Robotic Training Curriculum. Eur Urol 2015;68(2):292–9. DOI: 10.1016/j.eururo.2014.10.025.
8. Lovegrove C., Novara G., Mottrie A. et al. Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment. Eur Urol 2016;69(3):526–35. DOI: 10.1016/j.eururo.2015.10.048.
9. Urkmez A., Ranasinghe W., Davis J.W. Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy. Transl Androl Urol 2020;9(6):3036–48. DOI: 10.21037/tau.2020.03.36.
10. Briganti A., Larcher A., Abdollah F. et al. Updated nomogram predicting lymph node invasion in patients with prostate cancer undergoing extended pelvic lymph node dissection: the essential importance of percentage of positive cores. Eur Urol 2012;61(3):480–7. DOI: 10.1016/j.eururo.2011.10.044.
11. Mottet N., van den Bergh R.C.N., Briers E. et al. EAU-ESTRO-ESURSIOG Guidelines on Prostate Cancer 2018, in European Association of Urology Guidelines. 2018 Ed. 2018, European Association of Urology Guidelines Office: Arnhem, The Netherlands. p. 54.
12. Patel V.R., Tully A.S., Holmes R., Lindsay J. Robotic radical prostatectomy in the community setting – the learning curve and beyond: initial 200 cases. J Urol 2005;174(1):269–72. DOI: 10.1097/01. ju.0000162082.12962.40.
13. Vickers A.J., Savage C.J., Hruza M. et al. The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study. Lancet Oncol 2009;10(5):475–80. DOI: 10.1016/S1470-2045(09)70079-8.
14. Doumerc N., Yuen C., Savdie R. et al. Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years. BJU Int 2010;106(3):378–84. DOI: 10.1111/j.1464-410X.2009.09158.x.
15. Trinh Q.D., Sammon J., Sun M. et al. Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample. Eur Urol 2012;61(4):679–85. DOI: 10.1016/j.eururo.2011.12.027.
16. Rocco B., Matei D.V., Melegari S. et al. Robotic vs open prostatectomy in a laparo- scopically naive centre: a matched-pair analysis. BJU Int 2009;104(7):991–5. DOI: 10.1111/j.1464-410X.2009.08532.x.
17. Yossepowitch O., Briganti A., Eastham J.A. et al. Positive surgical margins after radical prostatectomy: a systematic review and contemporary update. Eur Urol 2014;65(2):303–13. DOI: 10.1016/j.eururo.2013.07.039.
18. Hong Y.M., Sutherland D.E., Linder B., Engel J.D. “Learning curve” may not be enough: assessing the oncological experience curve for robotic radical prostatectomy. J Endourol 2010;24(3):473–7. DOI: 10.1089/end.2009.0121.
19. Patel V.R., Palmer K.J., Coughlin G., Samavedi S. Robot-assisted laparoscopic radical prostatectomy: perioperative outcomes of 1500 cases. J Endourol 2008;22(10):2299–305. DOI: 10.1089/end.2008.9711.
20. Ploussard G., de la Taille A., Moulin M. et al. Comparisons of the perioperative, functional, and oncologic outcomes after robot-assisted versus pure extraperitoneal laparoscopic radical prostatectomy. Eur Urol 2014;65(3): 610–9. DOI: 10.1016/j.eururo.2012.11.049.
